2016 – 2017 New Student
Application
Dear Prospective LCA Parents,
Thank you for your interest in Lakeside Christian Academy. As we continue to grow numerically
and in the scope of the academic and athletic programs we offer, we feel it is important for us
as a school family to center ourselves on the philosophy and mission of our school. Should you
have any questions relating to this mission and philosophy, do not hesitate to ask. We look
forward to discussing these with you. We request that each new family meet with our School
Administrator to discuss your application and how we can meet your family’s needs.
Kindergarten and grade school students will also go through a grade appropriate evaluation
with their new teacher.
Sincerely,
Teachers, Staff & Board of Directors
School Mission Statement
The purpose of Lakeside Christian Academy shall be to operate an independent Christian school
that provides a creative, loving, and academic environment for children to grow spiritually,
socially, emotionally, physically, and academically through individual and group learning
experiences under the guidance and nurture of carefully chosen Christian teachers, and
administrators, under the Lordship of Jesus Christ. It shall be the purpose of LCA to encourage
all students to grow in a personal relationship with Jesus Christ and to emphasize the value of
the eternal soul, the worth of the individual, the love of God for man, and the kinship of all
peoples as taught in the Holy Scriptures, while providing students with the opportunity for
achieving academic excellence. The mission of LCA is to present the whole truth, for the whole
person, for the whole life, under the Lordship of Jesus Christ for the glory of God.
School Philosophy Statement
LCA shall provide each student the opportunity to study and develop the student’s spirit, mind,
and body in a wholesome, Christian environment. Being Christian in nature, LCA shall be
directed toward instruction concerning God’s will for each person and shall teach that all truth
is divine of origin. Knowledge to choose between good and evil, based upon God’s Holy Word,
shall be imparted to each child. Those serving LCA in any capacity, whether in administration,
on the faculty, on the staff, Board of Directors, or as a volunteer shall subscribe to LCA’s
philosophy of providing a high quality, Christian education in a Christian atmosphere. The
establishment and subsequent operation of LCA shall be successful only when done in
accordance with God’s will and for His honor and glory.
Believe. Serve. Achieve.
2016 – 2017 Tuition & Fees
Elementary
Grade
Tuition
½ Day Kindergarten
$4,037.00 / $336.42 monthly*
8:00 am – 11:30 am
Curriculum Fee
Due by September 6th
$100.00
Full Day Kindergarten
$4,697.00 / $391.42 monthly*
$100.00
st
th
1 – 5 Grades
$4,807.00 / $400.58 monthly*
$150.00
Application Fee (new families only) - $25.00
Registration Fee: $150.00
* Monthly payments require an ACH Withdrawal Agreement set up on a 9, 10, or 12-month schedule. Twelvemonth payment shown.
Middle School
Grade
Tuition
Curriculum Fee
Due by September 6th
th
th
6 – 8 Grades
$4,917.00 / $409.75 monthly*
$175.00
Application Fee (new families only) - $25.00
Registration Fee: $150.00
* Monthly payments require an ACH Withdrawal Agreement set up on a 9, 10, or 12-month schedule. Twelvemonth payment shown.
High School
Grade
Tuition
Curriculum Fee
Due by September 6th
th
th
9 – 12 Grades
$5,027.00 / $418.92 monthly*
$200.00**
Application Fee (new families only) - $25.00
Registration Fee: $150.00
* Monthly payments require an ACH Withdrawal Agreement set up on a 9, 10, or 12-month schedule. Twelvemonth payment shown.
** Curriculum fee for seniors will be waved when enrolled in the Early College program.
CURRICULUM FEES help cover consumable (student keeps) and non-consumable textbooks (school keeps) or
materials
MULTI-STUDENT DISCOUNT: Families that enroll two or more students at LCA will receive a 15% tuition discount
for each additional student. The student in the highest grade is always considered the first student.
EARLY PAYMENT DISCOUNT: Families that pay for the entire year by August 10th will receive a 5% discount.
FULL TIME MINISTRY DISCOUNT: Parents/guardians employed by a church in full-time vocational ministry for the
purposes of payroll and benefits reporting by the by-laws or regulations of the church, denomination, conference,
etc. may apply for this discount. These applications must be completed yearly and will be subject to availability
based on the Board of Director’s approval.
Notice of Student Non-Discriminatory Policy
Lakeside Christian Academy admits students of any race, color, national and ethnic origin, and grants them all
rights, privileges, programs, and activities generally accorded or made available to students at the school. It does
not discriminate on the basis of race, color national or ethnic origin in administration of its educational policies,
admission policies, athletics, and other school-administered programs.
Believe. Serve. Achieve.
New Student Information
STUDENT INFORMATION
Name: ___________________________________________________________________
LAST
FIRST
MIDDLE
PREFERRED NAME
Home Address: ________________________________________________________________________
STREET
CITY
STATE
Home Phone: (____) ____ - _____ Grade: _______ Date of Birth: ____/____/_____
ZIP
□ Male □ Female
What is the name of the church your family is currently attending? ________________________
Has this student ever repeated or been retained in any grade? □ No
□ Yes
If Yes, which grade? ______ Please explain: _________________________________________________
_______________________________________________________________________________________________________
Has this student ever been expelled, suspended, or have you ever been notified of behavioral problems?
□ No □ Yes
If Yes, give the name of the school and the details. ____ ________________________
_______________________________________________________________
______________________________________
Has this student ever been evaluated or referred for evaluation of learning difficulties or school adjustment
problems (ie: I.E.P., 504, …) by a school official, psychologist, or other professional? □ No
□ Yes
If Yes, give the name of the school and the details. __________________________________________
______________________________________________________________________________________________________
How would you rate your child’s health? □ Excellent
□ Good □ Fair
List any mental, emotional or physical handicaps which may affect the child’s activities or progress.
________________________________________________________________
________________________________________________________________
Does the applicant regularly require any medication? □ No □ Yes
If Yes, please explain.
__________________________________________________________________________________
Don’t let anyone look down on you because you are young, but set an example for the believers in
speech, in life, in love, in faith, and in purity. I Timothy 4:12
Believe. Serve. Achieve.
FAMILY INFORMATION
Check any that apply: Applicant lives with
□ Father □ Stepfather
□ Mother □ Stepmother
□ Name of Stepfather: ______________________________
□ Name of Stepmother: _____________________________
Check any that apply: Applicant’s
□ Father is deceased
□ Mother is deceased
□ Parents are divorced
□ Parents are separated
To whom should correspondence be sent? □ Both parents □ Father □ Mother
Parent(s) with whom child lives
Circle One
Father/Stepfather’s Name: _______________________________________________________________
Nickname
Circle One
Mother/Stepmother’s Name: _____________________________________________________________
Nickname
Home Address: ________________________________________________________________________
Street
City
State
Zip
Home Phone: (____) ____ - _____
Email Address: __________________________________________
Father / Stepfather’s Occupation: _________________________________________________________
Business Information:
_______________________________________________________________________
Name
Street Address
City
State & Zip
Work Phone: (____) ____ - _____ Cell Phone: (____) ____ - _____ Email: _________________________
Mother / Stepmother’s Occupation: ________________________________________________________
Business Information:
_______________________________________________________________________
Name
Street Address
City
State & Zip
Work Phone: (____) ____ - _____ Cell Phone: (____) ____ - _____ Email: _________________________
Parent(s) with whom child does NOT live (if applicable)
Circle One
Father/Stepfather’s Name: _______________________________________________________________
Nickname
Circle One
Mother/Stepmother’s Name: _____________________________________________________________
Nickname
Home Address: ________________________________________________________________________
Street
City
State
Zip
Home Phone: (____) ____ - _____
Email Address: __________________________________________
Believe. Serve. Achieve.
Sibling Information
Name: ____________________________ Age: _____ Current School: __________________________
Applying to LCA? □ No
□ Yes
Name: ____________________________ Age: _____ Current School: __________________________
Applying to LCA? □ No
□ Yes
Name of relatives who attend or are employed by Lakeside Christian Academy:
Name: ________________________________________ Relationship: __________________________
ADDITIONAL INFORMATION
Why do you want your child to attend Lakeside Christian Academy?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
What expectations do you have of your child as a student here?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Believe. Serve. Achieve.
STUDENT INFORMATION
Student Name ________________________________________
Last
First
Birthdate _____ / _____ / ______
Middle
Month
Day
Year
Contact Information:
Street Address ___________________________________ City ________________ State ____ Zip ______
Grade Entering _____ Home Phone (____) ____ - _____ E-Mail Address ______________________________
Father’s Name _______________________ Work Phone (____) ____ - _____ Cell Phone (____) ____ - _____
Mother’s Name ______________________ Work Phone (____) ____ - _____ Cell Phone (____) ____ - _____
Emergency Contact:
Name ___________________________ Work Phone No. (____) ____ - _____ Cell Phone (____) ____ - _____
Student’s Physician ___________________________________
Media Release:
My child’s picture may /
etc.
Phone (____) ____ - _____
may not be taken for school use such as website, advertisement, newspapers,
PAYMENT INFORMATION
We provide 3 different options for you to pay your tuition. Please check which method you will use:
 Monthly (must fill out attached ACH Agreement)
 Semesterly (due in 2 equal payments during the 1st week of August and January)
 Annually (must be received by August 10th to receive the 5% Early Pay discount)
APPLICATION CHECKLIST
The following documentation should accompany this application:
 ACH Withdrawal Agreement*
 Medical Treatment Consent Form
 Authorization for Child Pick-up
 Parent Covenant
 Curriculum Fee
 Application Fee of $25.00
 Registration Fee of $150.00 (for first child, $50 for each additional child)
*if applicable
Believe. Serve. Achieve.
Consent to Medical Care and Treatment of Minor Child
Child’s Name: ___________________________________
I am the natural parent/legal guardian of the above named child and I authorize and consent to
medical, surgical, and hospital care, treatment and procedures to be performed for my child by
a licensed physician when deemed immediately necessary or advisable by the physician to
safeguard my child’s health if I cannot be contacted. I waive my right of informed consent to
such treatment.
Father’s Signature: ______________________________________________________________
Date
Mother’s Signature: _____________________________________________________________
Date
Insurance Provider: _____________________________________________________
Policy Holder Name: ____________________________________________________
Group #: _____________________________________
ID #: ________________________________________
Preferred Hospital: ____________________________
Please list any ongoing medical issues or concerns we need to be aware of (i.e. any type of
allergies, asthma, etc.):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Believe. Serve. Achieve.
Authorization for Child Pick-up
We understand that children may be picked up by adults, other than their parent and/or
guardian. In order to protect your child, we are asking that you let us know, in advance, if you
will have someone picking your child up from school or a related function. You may preauthorize adults by completing the information below.
Please let the authorized person know that photo identification may be required if a staff
member is unfamiliar with them.
Student’s Name: ____________________________________________
Grade: ____________
Address: __________________________________________ City: ____________ State: _____
Mother’s Work Phone: (____) ____ - _______
Mother’s Cell Phone: (____) ____ - _______
Father’s Work Phone: (____) ____ - _______
Father’s Cell Phone: (____) ____ - _______
Authorized Person(s):
1. _____________________________________
Authorized Person’s Name (Please print)
2. _____________________________________
Authorized Person’s Name (Please print)
3. _____________________________________
Authorized Person’s Name (Please print)
4. _____________________________________
Authorized Person’s Name (Please print)
5. _____________________________________
Authorized Person’s Name (Please print)
6. _____________________________________
Authorized Person’s Name (Please print)
______________________________
Relationship to child & Contact Number
______________________________
Relationship to child & Contact Number
______________________________
Relationship to child & Contact Number
______________________________
Relationship to child & Contact Number
______________________________
Relationship to child & Contact Number
______________________________
Relationship to child & Contact Number
I/We authorize the above person(s) to pick up my child from school. I/We understand that
permission will be in place until a change is communicated, in writing, to the school.
______________________________________________________________________________
Parent Signature
Date
Believe. Serve. Achieve.
Parent Covenant
The School Board and Administration of Lakeside Christian Academy encourage our parents to
join together, pledging to uphold this covenant in order to glorify God through families,
teachers, and students that embody His grace. At least one parent must pledge support of this
covenant.
I/We as parent(s) understand, agree, and will commit to the following statement of support:
1. To guide our children through a biblical worldview, recognizing LCA as a supportive
partner. (Deuteronomy 6:5-7; Colossians 2:8; Matthew 22:37)
2. To pray earnestly for LCA, its families, faculty, staff, and administration. (James 5:16)
3. To serve the school in whatever capacity, with my time, and talents. (Mark 10: 43-45)
4. To preserve unity in the body by seeking to resolve any conflict within LCA by first
appropriately addressing the matter with the person, or persons, directly involved.
(Matt. 18:15-17)
5. To look for the good in our children’s behavior and to praise them for demonstrating
Christ-like character. (I Corinthians 13:4-7)
6. To communicate lovingly to other parents when we have valid concerns about their
child’s behavior, so that each of us as parents may guide our child to grow in Christ-like
character. (Colossians 3:12-17)
7. To attend school-related functions designed to foster a sense of community among LCA
parents, teachers, and staff. This will help equip all of us to work within the school and
one another, to educate our children, and to be more unified in our ability to encourage
one another in this high calling. (Hebrews 10:25)
8. We agree to be responsible for all financial obligations to Lakeside Christian Academy as
stated in the ACH Withdrawal Agreement. We understand that if we withdraw our
student during a semester, we are still required to pay the remaining semester’s tuition.
Families who are delinquent in keeping their accounts up-to-date may be asked to
withdraw their child until accounts are in order. (1 John 2:5)
___________________________________________________________________________
Parent Signature
Date
Believe. Serve. Achieve.
Parent & Student Agreement
Please read our school handbook then place a check mark in the space beside each statement
to indicate your agreement.
 We/I accept the challenge to “train up a child in the way he should go” (Proverbs 22:6)
and state this training will carry on in the home. We place our trust in Lakeside Christian
Academy (faculty, staff, and administration) to extend that training completely.
 We/I acknowledge that we have read the Parent-Student Handbook and agree to
uphold all standards and regulations therein.
 We/I pledge to support the school by praying for its program, staff, and by supporting
the procedures and discipline policies of the school.
 We/I agree to promote the spirit of unity within the ministry of the school. That is, we
agree that if in need of help with a school problem, we will follow the procedure
outlined in the Conflict Resolution Policy in the school handbook.
 We/I agree (parents only) to be responsible for all financial obligations to Lakeside
Christian Academy as outlined in the Tuition & Fees Policies in the school handbook.
Furthermore, we understand that if we withdraw our student during a semester, we are
still responsible for the remaining balance of tuition for that semester.
 We/I agree (student(s) only) to submit to the teachers, staff, and administration
leadership of Lakeside Christian Academy and do my part to take advantage of the
superior opportunity I have been given to obtain a first-class education in a Christian
environment.
Parent(s) Signature
Date
Student(s) Signature
Date
**All of our Handbooks are available on the school web site and in the
school office**
Believe. Serve. Achieve.
ACH Withdrawal Agreement
I (we) hereby authorize Lakeside Christian Academy, hereafter called COMPANY, to initiate
entries to my (our) Account indicated below at the Financial Institution named below, hereafter
called (THE FINANCIAL INSTITUTION), and, if necessary, initiate adjustments for any
transactions made in error. I (we) acknowledge that the origination of ACH transactions to my
(our) account must comply with the provisions of U.S. law.
________________________________________
Name of Financial Institution
Account Type:
Checking
Savings
Withdrawal Date:
1st of the month
15th of the Month
________________________________________
Address of Financial Institution – City, State & Zip
_________________________________
Routing Number
__________________________________
Account Number
Monthly Withdraw:
 Tuition
 Lunch
 After School
The tuition amount
will be a separate
withdrawal from
lunch and after school.
This authorization is to remain in full force and in effect until COMPANY has received written
notification from me (or either of us) of its termination in such time and in such manner as to
afford COMPANY and FINANCIAL INSTITUTION a reasonable opportunity to act on it.
Name(s): ______________________________________________________________________
(Please Print)
Signature: _____________________________________________________________________
Date
Please attach a VOIDED CHECK.
ADMINISTRATIVE FEE NOTICE:
A one-time $35.00 fee will be added to your first month’s payment in order to cover the cost of
administering your monthly payment plan.
Believe. Serve. Achieve.
Student Records Release Authorization
Previous School: _______________________________________________________________
Street Address: ________________________________________________________________
City/State/Zip: _________________________________________________________________
Phone: (____) ____ - _____
Fax: (____) ____ - _____
Dear Administrator/Registrar:
The following student has enrolled in our school. Please forward his/her cumulative records to
Lakeside Christian Academy. Please include all report cards, test scores, health/immunization
records, and any special program needs.
Student Name
Age and
Date of Birth
Grade at
Withdrawal
Current
Grade
I give my permission for the above records to be released.
_____________________________________
Parent/Guardian name (please print)
___________________________________
Signature of Requesting Registrar
_____________________________________________________________________________
Parent/Guardian Signature
Date
PLEASE DELIVER RECORDS TO:
Lakeside Christian Academy
2535 Us 60 West
Morehead, KY 40351
PH (606) 784 – 2751 FAX (606) 784 – 0056
Believe. Serve. Achieve.